Tackling a diabetes epidemic

DIABETES is nearly four times as common as all types of cancer combined and is fast becoming a major 21st century crisis. Around 2.9 million people in the UK have been diagnosed with a form of the disease but it’s thought that as many as 850,000 people have type 2 diabetes but do not yet know.

The figures are staggering and are a major source of concern for healthcare professionals across the UK. As part of the attempt to fight this rising tide, the Department of Health is carving out a greater role for primary care physicians in the prevention, early detection and treatment of this condition.

Part of this strategy involves a greater role for GPs with a special interest (GPwSI) in diabetes.

A GPwSI is a doctor, working principally in the community, who takes referrals that may otherwise have gone directly to a secondary care consultant and delivers a clinical service beyond the scope of their core generalist role.

They will have demonstrated appropriate competences to deliver those services without direct supervision. In some cases they work with the specialist team to present the views of general practice in discussions on local guidance and policy, and also provide advice on commissioning.

There are many GPs who currently provide specialist diabetes services but who do not consider themselves to be special interest practitioners. For those doctors who do wish to achieve official GPwSI status, there is a formally accredited framework set out by the Department of Health in their document Guidance and competences for the provision of services using practitioners with special interests – Diabetes.

Training

The GPwSI competency framework document for diabetes details the type of evidence and competences that may be expected from GPwSIs in diabetes during the accreditation process.

The competences are as follows:

• Understand the clinical management of diabetes

• Provide and monitor drug therapy for clinical management of diabetes

• Manage the delivery of diabetes care

• Deal with diabetic emergencies

• Understand the special needs of older people with diabetes

• Understand and manage the complications of diabetes:

     - screening
     - microvascular disease
     - eye disease
     - renal disease and hypertension
     - neuropathy, foot disease and erectile dysfunction.

GPwSIs are expected to demonstrate that they have completed recognised training which may include acknowledgement of prior learning and expertise. Training can be acquired in several ways and would be expected to include both practical and theoretical elements. It is essential to undertake attachments to specialist care diabetes services over a reasonable period of time to reach the necessary level of competence.

Other routes through training include gaining experience of working in relevant departments; self-directed learning with evidence of completion of individual tasks; attendance at recognised meetings/lectures/tutorials on specific relevant topics; practising as a trainee under the supervision of a diabetes specialist/consultant in the secondary care service; and completing a recognised university course.

Recognised courses include the postgraduate diploma in diabetes for practitioners with a special interest, offered by the University of Bradford. The part-time course comprises a large element of work-based and shared learning. Warwick Medical School also provide a certificate in diabetes care while Cardiff University offer a postgraduate diploma in diabetes.

In practice

GPwSIs are most likely to work in the community, normally with links to the specialist care sector. The core activities of a GPwSI diabetes will vary depending on local needs and resources. Examples of the types of clinical services that practitioners could deliver include:

• Addressing the needs of hard-to-reach patient groups, e.g. household / care home residents

• Working within a multidisciplinary team environment under locally agreed protocols for the management of non-urgent / routine / ongoing care diabetes

• Dealing with patients with new or progressing problems, including starting insulin and GLP1 medication

• Providing primary care input into local policy and guideline development.

Practitioners may also be commissioned to provide relevant elements of diabetes care such as specialist eye and foot care and a specialist dietetic service. Complications from diabetes affect every organ in the body making it a potential area of interest for doctors with interests in a range of specialties, from cardiology to neurology.

A big feature of primary care diabetes clinical services is the focus on multidisciplinary team work, so if you are the type of person who enjoys working in this way then taking an interest in this field presents an ideal opportunity.

Links:

• The Primary Care Diabetes Society www.pcdsociety.org

• Association of British Clinical Diabetologists www.diabetologists-abcd.org.uk

Q&A: Dr Peter Livingstone, Locum GP with a special interest in diabetes

What attracted you to a career as a GPwSI in diabetes?

I found the science of diabetes extremely interesting from the cellular level. With the use of insulin or medication I found I could make patients better and prevent secondary complications. The area is so vast and the management is constantly changing and I enjoy the challenge that presents.

What do you enjoy most about the job?

Team work! Prior to the commencement of each clinic the team, which consists of me, the consultant, diabetic specialist nurses, dietician and podiatrist, all sit down together and discuss each individual patient, reflecting on their previous attendance and glycaemic control and what further options are available.

Are there any downsides?

Some patients are in denial in relation to their diagnosis of diabetes and therefore do not take any responsibility for their diabetes. I struggle at times watching people being admitted with diabetic ketoacidosis or developing secondary complications such as severe retinopathy knowing full well that if they had accepted their diagnosis they would not be in that situation.

What do you find most challenging?

The management of diabetes is constantly changing, whether it is insulin pumps, pancreatic islet cell transplantations or medication. It can be difficult keeping up-to-date with new medications and technology so there is a lot of reading to be done.

What about the role has most surprised you?

It is nice to find yourself in a position where you can actually make a difference to individuals’ lives by doing something simple such as slightly adjusting a patient’s medication or insulin as this can have a major improvement on their glycaemic control.

What is your most memorable experience so far?

Watching a gentleman who I thought was going to have a below-knee amputation due to a severe neuropathic ulcer walk again after intensive treatment from the multi-disciplinary team.

What advice would you give to a trainee GP considering a career as a GPwSI diabetes?

I did my postgraduate diploma in diabetes and would recommend this to anyone. This is a two-year, long distance course which critically evaluated the evidence on the management of diabetes. This is not essential for the job but sets you in good stead. If you show interest in this area you should find you are almost certain to get a job somewhere!